Pneumonia

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  1. Clinical Presentation of Pneumonia: S/Sx
    • • Abrupt onset of fever, chills, dyspnea, and productive cough
    • • Rust-colored sputum or hemoptysis, pleuritic CP
  2. Clinical Presentation of Pneumonia: S/Sx (Respiratory)
    • • Dyspnea
    • • Cough
    • • Fever
    • • Sputum production
    • • Chills
    • • Pleuritic chest pain
  3. Clinical Presentation of Pneumonia: S/Sx (Hemodynamic)
    • • Hypotension
    • • Shock
    • • Tachycardia
  4. Clinical Presentation of Pneumonia: S/Sx (Extratoracic)
    • • Otitis, pharyngitis
    • • Skin alteration
    • • Hemolytic anemia
    • • Headache
    • • GI symptoms
    • • Confusion
    • • Hyponatremia
  5. Clinical Presentation of Pneumonia: Physical Examination
    • • Tachypnea and tachycardia
    • • Dullness to percussion
    • • Increased tactile fremitus, whisper pectoriloquy, and egophony
    • • Chest wall retractions and grunting respirations
    • • Diminished breath sound over affected area
    • • Inspiratory crackles during lung expansion
  6. Clinical Presentation of Pneumonia: Chest Radiography
    • Dense lobar or segmental infiltrate
  7. Clinical Presentation of Pneumonia: Labs
    • • Leukocytosis with predominance of PMNs
    • • Low oxygen saturation on arterial blood gas or pulse oximetry
  8. Other Diagnostic Tests
    • • Tests for etiology
    • → Blood cultures, sputum culture, Legionella urinary antigen, Pneumococcal urinary antigen
    • • CRP
    • → If less than 20 mg/L without convincing diagnosis may not need antibiotics for CAP
    • • PCT
    • → If <0.1 mcg/L antibiotics discouraged
    • → If >0.25 mcg/L antibiotics encouraged
    • → If >0.5 mcg/L antibiotics strongly encouraged
  9. CAP
    • • Definition
    • → Pneumonia developing in patients with no contact to a medical facility
    • • Symptoms
    • → Sudden onset of fever, chills, pleuritic chest pain, ±productive cough, dyspnea
    • • Radiographic examination
    • → Lobar or subsegmental infiltrate
    • • No risk factors for HCAP
    • • Occurs as an outpatient or < 48 hours after admission or incubating at time of admission
  10. CURB-65 in CAP
    • • Confusion (based on specific mental test or disorientation to person, place, or time)
    • • Uremia: BUN level >20 mg/dL
    • • Respiratory rate ≥30 breaths/min
    • • Low Blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg)
    • • Age ≥65
    • • 0-1: Outpatient
    • • 2: Outpatient or inpatient
    • • 3: Inpatient
    • • 4-5: Inpatient ( ICU)
  11. CAP ICU Admission Criteria
    • • ≥ 3 minor criteria
    • → Respiratory rate ≥30 breaths/min
    • → PaO2/FiO2 ratio ≤250
    • → Multilobar infiltrates
    • → Confusion/disorientation
    • → Uremia (BUN level ≥20 mg/dL)
    • → Leukopenia (WBC count <4000 cells/mm3)
    • → Thrombocytopenia (platelet count <100,000 cells/mm3)
    • → Hypothermia (core temperature <36◦C)
    • → Hypotension requiring aggressive fluid resuscitation

    • • ≥ 1 major criteria
    • → Invasive mechanical ventilation
    • → Septic shock with the need for vasopressors
  12. CAP Usual Micoorganisms
    • “Should Have put A CAP on My Childs Lungs”
    • • Streptococcus pneumoniae
    • • Haemophilus influenzae
    • • Atypicals
    • → Mycoplasma pneumoniae
    • → Chlamydophila pneumoniae
    • → Legionella pneumophila (Freshwater exposure/environments, serious pneumonia, need for hospitalization)
  13. Outpatient CAP Microorganisms
    • • Streptococcus pneumoniae
    • • Mycoplasma pneumoniae
    • • Haemophilus influenzae
    • • Chlamydophila pneumoniae
    • • Respiratory viruses
  14. Inpatient (non-ICU) CAP Microorganisms
    • • Streptococcus pneumoniae
    • • Mycoplasma pneumoniae
    • • Haemophilus influenzae
    • • Chlamydophila pneumoniae
    • • Legionella species
    • • Aspiration
    • • Respiratory viruses
  15. Inpatient (ICU) CAP Microorganisms
    • • Streptococcus pneumoniae
    • • Staphylococcus aureus
    • • Legionella species
    • • Gram-negative bacilli
    • • Haemophilus influenza
  16. CAP Drug-resistant S. pneumoniae (DRSP) Risk Factors
    • • Age <2 years or >65 years
    • • Antibiotic therapy within the previous 3 months
    • • Alcoholism
    • • Medical comorbidities
    • • Immunosuppressive illness or therapy
    • • Exposure to a child in a day care center
  17. CAP Drug-resistant Community Acquire-MRSA Risk Factors
    • • End stage renal disease
    • • IV drug abuse
    • • Prior influenza
    • • Prior antibiotic therapy
    • • Carries the gene for the Panton-Valentine leukocidin (PVL) toxin,
    • → Clinical presentation of cavitary lung lesion
  18. CAP Drug-resistant Pseudomonas aeruginosa Risk Factors
    • • Cystic fibrosis
    • • COPD
    • • Bronchiectasis
    • • Not common in CAP
  19. CAP Outpatient Treatment (No Risk Factors for DSRP)
    • • Duration: Minimum of 5 days. Most patients treated for 7-10 days or longer
    • • Macrolide
    • → Azithromycin 500 mg (Day 1), 250 mg Daily (Days 2-5)
    • • Doxycycline 100 mg BID
  20. CAP Outpatient Treatment (Comorbidities and/or No Risk Factors for DSRP)
    • • Duration: Minimum of 5 days. Most patients treated for 7-10 days or longer
    • • Levofloxacin 750 mg IV/PO Daily
    • • Moxifloxacin 400 mg IV/PO Daily
    • • β-lactam PLUS a macrolide (or doxycycline)
    • → Amoxicillin-clavulanate 2g PO BID (preferred)
    • → High-dose amoxicillin 1g PO TID
    • → Cefpodoxime 200 mg PO BID
    • → Cefuroxime 500 mg PO BID
    • → Ceftriaxone 1g IV Daily
  21. CAP Atypical Coverage
    • • M. pneumo, C. pneumo, Legionella
    • → Macrolides
    • → Fluoroquinolones
    • → Tetracyclines
  22. CAP Inpatient Treatment (Moderately-Severe)
    • • Levofloxacin 750 mg IV/PO Daily
    • • Moxifloxacin 400 mg IV/PO Daily
    • • β-lactam PLUS a macrolide (or doxycycline)
    • → Ceftriaxone 1-2 g IV Daily
    • → Ampicillin 1-2 g IV Q4-6H
    • → Azithromycin 500 mg (Day 1), 250 mg Daily (Days 2-5)
    • → Azithromycin 500 mg IV x3 days
  23. CAP Inpatient Treatment (Severe requiring ICU admission)
    • • β-lactam PLUS respiratory FQ or macrolide
    • → β-lactam: ampicillin-sulbactam 1.5-3g IV q6h or ceftriaxone 1-2g IV daily
    • → FQ: moxifloxacin 400 mg IV daily or levofloxacin 750 mg IV daily
    • → Macrolide: azithromycin 500mg IV
    • • May need to broaden coverage if suspecting P. aeruginosa or MRSA (Ex. CA-MRSA)
    • → Vancomycin or clindamycin
    • → Ceftaroline (newer agent)
  24. CAP Tx Duration
    • • Longer duration may be necessary with the following
    • → Initial therapy was not active against the identified pathogen
    • → Complicated by an extrapulmonary infection
    • → Bacteremic S. aureus pneumonia
    • → Presence of cavities or other signs of tissue necrosis
    • → Infected with less common pathogens (e.g., Burkholderia pseudomallei or endemic fungi)
    • → Pseudomonas aeruginosa pneumonia
  25. Healthcare-Associated Pneumonia (HCAP)
    • • Hospitalized for ≥ 2 days within 90 days of infection
    • • Resided in nursing home or long-term care facility
    • • Received recent IV antibiotic therapy, chemotherapy, or wound care within 30 days of infection
    • • Chronic dialysis within 30 days
  26. Hospital-Acquired Pneumonia (HAP)
    Occurs ≥ 48 hours after admission, not incubating at time of admission
  27. Ventilator-Associated Pneumonia (VAP)
    Arises > 48 to 72 hours after endotracheal intubation
  28. Nosocomial Pneumonia Most Common Microorganisms
    • • S. aureus
    • • P. aeruginosa
    • • Klebsiella
  29. Nosocomial Pneumonia: Early Onset HAP, Not at Risk of MDR Microorganisms
    • • MSSA
    • • H. influenza
    • • Strep pneumo
    • • Enterobacter
    • • E. coli
    • • Klebsiella
  30. Nosocomial Pneumonia: Early Onset HAP, at Risk of MDR Microorganisms
    • • MSSA
    • • H. influenza
    • • Strep pneumo
    • • Enterobacter
    • • E. coli
    • • Klebsiella
    • • Serratia
    • • Proteus
  31. Nosocomial Pneumonia: Late Onset HAP Microorganisms
    • • MRSA
    • • P. aeruginosa
    • • Actinobacter baumannii
    • • Enterobacteriaceae expressing ESBL and AmpC E-lactamases, conferring resistance to PCNs and cephalosporins
    • • Polymicrobial
  32. Nosocomial Pneumonia: Risk Factors for MDR Pathogens
    • • Current hospitalization ≥ 5 days
    • • Antimicrobial therapy in preceding 90 days
    • • High frequency of antibiotic resistance in the community or in the specific hospital unit
    • • Presence of risk factors for HCAP
    • → Hospitalization for 2 days or more in the preceding 90 days
    • → Residence in a nursing home or extended care facility
    • → Home infusion therapy (including antibiotics)
    • → Chronic dialysis within 30 days
    • → Home wound care
    • → Family member with MDR pathogen
    • • Immunosuppressive disease and/or therapy
    • • Additional development and validation of prediction scores based on more refined risk factors still need
  33. Nosocomial Pneumonia: Early Onset and No Risk for MDR Pathogens
    • • Duration: 14-21 days
    • • Ceftriaxone 1 g IV Daily
    • • Fluoroquinolones
    • → Levofloxacin 750 mg IV daily
    • → Moxifloxacin 400 mg IV daily
    • • Ampicillin/sulbactam 3 g IV q6h
    • • Ertapenem 1 g IV daily (reserve for select patients)
  34. Nosocomial Pneumonia: Late Onset or if P. aeruginosa
    • • Duration: may require longer than 14-21 days
    • • Antipneumococcal, antipseudomonal β-lactam
    • → Piperacillin-tazobactam 4.5 g IV q6h (extended infusion)
    • → Cefepime 1-2 g IV q8-12h
    • → Ceftazidime 2 g IV q 8h
    • → Imipenem 500 mg IV q6h or 1 g IV q8h
    • → Meropenem 1 g IV q8h
    • → OR if PCN-allergic: substitute aztreonam for above β-lactam
    • • PLUS
    • → Ciprofloxacin or levofloxacin
    • → OR an aminoglycoside + azithromycin
    • → OR an aminoglycoside + respiratory fluoroquinolone
  35. Nosocomial Pneumonia: Late onset or if MRSA
    • • Same as Late Onset or if P. aeruginosa PLUS
    • • Add vancomycin (goal trough 15-20) or linezolid 600 mg IV q12h
    • → Alternative: telavancin (newer agent for HAP/VAP)
  36. Aspiration Pneumonia
    • • May occur due to aspiration of colonized gastric contents into the lower respiratory tract
    • • Risk factors: decreased consciousness, impaired swallowing, NG tube/ET tube/tracheotomy, periodontal disease, elevated gastric pH
    • • Tx: Beta-lactam/beta-lactamase inhibitor combinations, carbapenems, clindamycin

Card Set Information

Author:
ebmalonzo
ID:
316178
Filename:
Pneumonia
Updated:
2016-02-20 18:10:56
Tags:
pneumonia
Folders:
ID 1
Description:
ID 1 (Final): Pneumonia
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